1. Reducing disparities in perinatal outcomes: looking upstream May 8, 2006 Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health University of California, San Francisco www.ucsf.edu/csdh

2. The case for prevention  LBW/PTB  Serious cognitive, emotional- behavioral and physical disabilities Placing affected individuals at disadvantage across life course Burden on families Societal costs—human, economic  A gradient of adverse outcomes across the birthweight distribution—not just the extremes  Values: equalizing opportunities to be healthy

3. Causes of LBW & PTB  Known Tobacco Excessive alcohol Drugs Nutrition Short maternal stature Chronic disease  Suspected Infections? Genes? Stress? lack of social support as a stressor and/or modifier of effects of stress?

4. Causes of LBW & PTB disparities  Only partly explained by: Tobacco Excessive alcohol Drugs Nutrition Chronic disease  Infections? Rx hasn’t improved outcomes  Genetic component? Hypothetical Some patterns don’t fit  Stress? Accumulating evidence

5. Stress and its influence on PTB & LBW  Physiological pathways have been documented in humans  Neuro-endocrine pathways ― e.g., release of hormones that could trigger vascular effects and/or premature labor  Immune/inflammatory pathways

6. Sources of stress  Range of psychosocial stressors associated with poverty/lower income Divorce/separation, moving, job loss, financial insecurity, food insecurity, domestic violence, lack of social support Women of color experience more poverty/low-income and more stressors  We have found high rates of stressors among low- income pregnant women in California and 17 other states, e.g…

7. Separated/divorced during pregnancy, by income group, California MIHA 2003

8. Partner’s job loss during her pregnancy, by income (similar pattern for her job loss)

9. Often could not afford to buy enough food during pregnancy, by income group

10. Understanding the causes of LBW/PTB disparities  More questions than answers, but what can we learn from the patterns? By SES and by race or ethnic group Racial disparities are greater among higher SES women vs. lower SES women Difficult to explain with genetics By nativity (born in vs. outside US)

11. Disparities by nativity Latinas  Immigrants have good birth outcomes despite poverty, low education, less care  US-born have unfavorable outcomes Blacks  African/Afro- Caribbean immigrants have relatively good outcomes  US-born (African- Americans) have unfavorable outcomes

12. Nativity patterns  Difficult to explain with genetics  Nativity differences persist even after considering healthier “lifestyle” Immigration is stressful, so difficult to explain by stress in general What about chronic stress &/or at critical periods, e.g., awareness of discrimination in childhood for US-born? Resources that buffer effects of stress?

13. Life course exposure to stress  Poverty/lower income in childhood, adolescence (& adulthood before pregnancy) could be stressful  Black women of a given SES are more likely to have had lower SES as children (vs. Whites of similar income/education now)  Weathering hypothesis – cumulative stress  But could past exposures lead to LBW/PTB in current pregnancy, if a woman is no longer poor? Yes: e.g., via neuroendocrine dysregulation

14. Racism as a source of chronic stress – cumulative across life course  Stress associated with unfair treatment Concern about being treated unfairly, based on being in a group that has historically suffered discrimination even without major incidents of clear-cut discrimination  Some studies have linked racism with adverse birth outcomes; some have not  Inadequate measures; we (Nuru-Jeter et al.) are trying to systematically develop measures for birth outcomes research  Could racism help explain racial disparities and nativity paradoxes?

15. Role of public health  Targeted programs to reduce the known risk factors (smoking, under-nutrition, etc) ― even though these don’t account for all the disparities  Encourage life course research on psychosocial factors  Bold experiments with plausible interventions  Support efforts with/by other sectors to reduce stress health-damaging effects of poverty/near- poverty and racial discrimination